WRIST , DIGITAL , PENILE , FACIAL BLOCK

WRIST , DIGITAL , PENILE , FACIAL BLOCK

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WRIST BLOCK
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(Reference:
https://osler.ucalgary.ca/ume/proskills/NBlockWrist/NBWristArticle.htm
http://bentollenaar.com/_MM_Book/Ch.17.htm)

(Netter 461, 467, 468 참조)

Injection for the Median Nerve
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Find the Palmaris longus, at 1cm proximal to the distal wrist flexion crease.
[The Palmaris longus can be found as follows:
find the radial artery, roll your fingers toward the ulnar side to feel for the first tendon
(this will be the flexor carpi radialis), now roll and feel for the second tendon which will be the Palmaris longus.]
(Note that palmaris longus may be absent in some people)

Move and aim just off the radial side of the Palmaris longus (and medial to the flexor carpi radialis).
Insert the needle perpendicularly and advance slowly until a ‘pop’ through the transverse carpal ligament (aka flexor retinaculum).

Inject 3-5mL just deeper than the Palmaris longus tendon.

Inject some subcutaneously to block superficial branch of median nerve.


Injection for the Ulnar Nerve
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Two ways: lateral approach and volar approach (volar approach is more difficult and is omitted here)

Lateral Approach:

At the proximal palmar crease, insert the needle on the ulnar aspect of the flexor carpi ulnaris tendon.
[The flexor carpi ulnaris can be found as follows: find the ulnar artery, and roll your fingers in an ulnar direction over the first tendon

which will be the flexor carpi ulnaris.]

Advance horizontally under the tendon 1.0-1.5cm (paresthesia should be elicited to confirm proper position close to the nerve within

the thick neurovascular bundle). Alternatively, advance the needle toward the ulnar bone deep to the flexor carpi ulnaris and inject

as needle is being withdrawn.

Cutaneous nerves branch off the ulnar nerve to wrap around the wrist and supply the dorsum of the hand. Block these with a 5-10mL

SQ(subcutaneous) band of anesthetic from the lateral boarder of the flexor carpi ulnaris to the dorsal midline. Note: if the lateral

approach is used, the same injection site can be used to block these dorsal branches.


Injection for the Radial Nerve
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Block branches with a 5-10mL SQ band of anesthetic from the primary injection site to the dorsal midline


주의
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Nerve 안에 주사하면 안됨. (causes intense pain)

Nerve 주위에 주사하는 것임. (causes sensation of pins and needles)


(Elicitation of Paresthesias

It is important to ascertain that the needle is making contact with the nerve rather than penetrating it, and that the injection is in

proximity to the nerve (perineural) rather than within its substance (intraneural).
The high pressures generated by a direct intraneural injection can cause hydrostatic (ischemic) injury to nerve fibers. A perineural

injection may produce a brief accentuation of the paresthesia, whereas an intraneural injection produces an intense, searing pain

that serves as a warning to immediately terminate the injection and reposition the needle.
Pain intensity and duration help differentiate between accentuation and intraneural injection.)


Local anesthetic
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Lignocaine(Xylocaine):
-onset: 2~5 min
-duration: 1 hr
-max dose: 3 mg /kg

Bupivacaine(Marcain):
-onset: 15 min
-duration: 4 hrs
-max dose: 2 mg /kg


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DIGITAL BLOCK
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http://www.youtube.com/watch?v=25kZWI_MYrg


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PENILE BLOCK
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Key anatomical area:
The triangular space lying deep to the fascia, bounded above by the symphysis pubis and below by the corpora cavernosa

Area to watch out:
Avoid 12 o'clock dorsum - has vessels. if penetrated can cause hematoma.

The technique involves inserting the needle until ittouches the pubic symphysis.  This gives a guide todepth.
The needle is then withdrawn and redirected to pass below the symphysis and 3-5 millimetres deeper depending on the size of the patient. It is preferable to direct it slightly laterally into the pear shaped space and then to re-insert in on the other side depositing equal volumes on each side. Avoiding the midline injection reduces the chance of penetrating the dorsal vessels of the penis and causing haematoma. If a short beveled needle the fascia may be felt as a slight resistance when it is penetrated, but in small children this is not always felt as it is thin and may offer little resistance.

(reference:
http://www.google.co.za/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&ved=0CDMQFjAB&url=http%3A%2F%2Fupdate.anaesthesiologists.org%2Fwp-content%2Fuploads%2F2009%2F10%2FPenile-Block.pdf&ei=dOmoUeCcLqKu7AbEzYHIDg&usg=AFQjCNGH4R1wqGV4e94fC-noyknDWV4vcQ&sig2=EH8mZAFk-afpO7MRhJsN3A
http://pgmedic.blogspot.com/2011/11/dorsal-penis-block.html)

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FACIAL BLOCK
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(REFERENCE:

 http://johnpaoli.com/post/459714022/facial-nerve-blocks-injection-sites-and)